BREAK REQUEST Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastSEVIS # *Email *US Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code plan / SEVIS Shift *--- Select Choice ---Academic MorningAcademic EveningInteractive FridaysInteractive MondaysLevel *--- Select Choice ---Academic - FundamentalsAcademic - BeginningAcademic - Pre-IntermediateAcademic - IntermediateAcademic - High-IntermediateAcademic - AdvancedAcademic - TOEFLAcademic - Advanced +Interactive - Level 3Interactive - Level 4Interactive - Level 5Interactive - Level 6Interactive - Level 7Interactive - Level 8Break request requirements: To be eligible for a break, students must meet all of the following conditions: 1)Have completed at least two consecutive semesters without interruption, with: -A minimum of 80% attendance, and -A 70% overall grade average. 2)No outstanding balance or overdue payments with Internexus Provo. 3)Pay a $150 non-refundable tuition deposit before the break begins. -This amount will be credited toward your next semester’s tuition upon return. How to request a break: 1)Complete all fields on this Break Request Form. 2)Submit your request by the previously established due date. ⚠️ Note: Your request must be submitted at least 15 days before your intended break start date. 3)Processing time: You will receive a decision within 15 business days of the end of the semester. Break Policy Guidelines: 1)The $150 advance payment is non-refundable, even if you request a school transfer during or after the break. 2)Breaks must end at the end of a session (not in the middle of a session). 3)You must not make travel plans or leave until you receive written approval from Internexus Provo administration. 4)A confirmation letter will be issued once your break is officially approved. Please do not make any travel plans without first receiving the approval letter from Internexus Provo’s administration in hands. Academic Verification Required:Please provide the name of the school you attended during the last two semesters, along with the dates you were enrolled. -If you did not study at Internexus Provo for the past two consecutive semesters, please attach official transcripts from your previous school(s). 1 - School *Please provide the name of the school you attended your first semester, along with the dates you were enrolled. (If you studied at Internexus Provo, please list “Internexus Provo.”)1 - From / DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201 - To / DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119202 - School *Please provide the name of the school you attended your second semester, along with the dates you enrolled. (If you attended Internexus Provo, please list “Internexus Provo.”)2 - From / DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119202 - To / DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I would like to officially request a break from my studies: Semester / year3 - From / Date MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119203 - From / DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I would also like to inform that during this break: I plan to visit another country outside of the United States. *YesNoPlease specify which countries:(To leave the country you must ALWAYS talk to the DSO first!) I plan to visit other states inside of the U.S.A. *YesNoRequest *BREAK FORMDetailsFile Upload Drag & Drop Files, Choose Files to Upload Electronic signature * Clear Signature I understand it takes between 24 and 48 hours to process my request.Submit